Case 41:

Discussant: JOHN PRIMROSE, MD

Case Description:

An 80-year-old man presents with a nonobstructing cecal cancer and synchronous significant right sided liver metastases. His left hemiliver was notably small. Hence, a right PVE was performed, yielding successful hypertrophy within four weeks. He was then brought to surgery where he underwent a right hepatectomy and wedge resection of segment III (intraoperative finding of additional left lobe lesion) in addition to a right hemicolectomy. He declined postoperative chemotherapy, despite an uncomplicated postsurgical course.

Case Discussion:

DR PRIMROSE: This was an 80-year-old patient who presented with a primary nonobstructing cecal cancer and synchronous extensive right-sided liver metastases. A number of challenges were associated with this case. The patient had a notably small left lobe, which likely represented inadequate hepatic reserve status post resection of the involved right liver. This patient underwent PVE of his right liver followed by a synchronous resection of his liver and cecal cancer in one sitting. He was then offered postoperative chemotherapy, but the patient decided against it. This case raises several controversies, including the issue of synchronous versus scheduled resection of the sites of disease.

In general, if the liver resection is straightforward — which this turned out to be — and a right colonic tumor is present, it is perfectly reasonable to combine the surgeries. It’s technically much simpler to perform a right colonic resection than a left colonic resection, together with the liver resection. So we did this with no particular problems.

I believe that administering preoperative chemotherapy for three months followed by synchronous liver and colon surgery may have been a little bit much for someone of this age, and I think the decision not to use that approach was probably the right one. The decision about postoperative chemotherapy was entirely the patient’s. My own view is that, if it were me, I would want to have standard adjuvant chemotherapy, probably with FOLFOX. But the patient refused therapy. I have performed a liver resection in a 90-year-old, but he didn’t have chemotherapy. I think 90 years of age is pretty much the upper age-limit for performing liver surgery.

If the primary tumor is asymptomatic, I treat it with chemotherapy first or chemoradiation therapy if the patient has rectal cancer — if the primary disease is asymptomatic, there’s no urgency to deal with it. Dealing with a systemic disease is, I think, the more important thing.

In patients who never have resectable liver disease, some controversy exists about whether you should ever take the primary tumor out, if it’s not symptomatic. In fact, a proposed trial in the UK is randomly assigning patients with inoperable metastatic disease to either immediate or delayed resection of the primary tumor. I don’t think we know the answer. Some studies suggest it’s better to take the primary tumor out, but I don’t think everybody accepts this. It’s a common area of debate for surgeons.

PVE usually causes no symptoms or toxicity. We can perform PVE as a day case or a single overnight stay in hospital. We would perform it during chemotherapy and not be concerned about the additive toxicity. We’ve had no problems at all, and I think most people who work in this area haven’t had any problems, so we can use both together. The patient will undergo the PVE and, while we’re waiting for hypertrophy, the patient can receive chemotherapy. The best data on the time to hypertrophy are from Nick Groatae at MD Anderson. I believe that most of the hypertrophy occurs within a month, and it peaks within two months. If you combine PVE with chemotherapy, hypertrophy can take a little more than three months, so if you perform embolization shortly after the induction of the chemotherapy, the timing works out quite well.